Below are responses to questions about the Mitigation & Penalties Approach and the new Cycle for Fire Marshal Inspections
Will the PowerPoint be available?
The PowerPoint slides presented in the webinar will be available on the BALC website soon, and were emailed out to all CILA providers after the webinar. They are also available upon request. Please email DHS.BALC@illinois.gov
Will the mitigation template be available on the BALC website?
Yes, the Mitigation template is available on the BALC website to download: Get the Mitigation Plan Excel document to complete here (xlsx)
*Note due to accessibility requirements the version on the website has the required Provider Mitigation Plan on the second tab
We have many sites that have not had an inspection for a couple of years. How will those be handled?
Regardless of how long ago the last inspection was, if there are open unresolved violations we required the violation list and mitigation plan. If your last inspection passed, but the passed inspection was prior to Sept 1st 2019, (out of two year compliance) it will need to be seen and you will need to submit a fire inspection request form. But a mitigation plan is not required.
If we had no findings at the time of last inspection, do we need to do the proactive mitigation plan?
No, if you have no open violations you do not need to submit a Mitigation plan, but you do need to respond and inform BALC that you have no open violation and will thus not be submitting a mitigation plan.
Who will be on the receiving end of the mitigation plans? Or, where do I send them to?
The mitigation plans are to be sent to the BALC email at this address DHS.BALC@illinois.gov in Excel file format per the example template sent through email communication and available to download on the BALC website: Get the Mitigation Plan Excel document to complete here (xlsx)
If all the corrections are done do I have to submit a mitigation plan with my fire inspection request?
Yes. Moving forward Providers are required to provide a written mitigation plan to BALC before a request to schedule the fire marshal re-inspection for open violations. If the corrections are already complete you may submit the Mitigation Plan and the Fire Inspection request together.
If a local fire authority conducts a fire inspection, will the Mitigation & Penalties apply? And how will it affect the 4 year cycle?
This fire inspection reports that are required by rule for licensure and certification are inspections conducted by the Office of the State Fire Marshal (OSFM). As part of these inspections, some requirements might include documentation of local FD reviews of your alarm systems or other features of your site. These are outlined in the NFPA 2015 Life Safety Code. The reports and violations issued by the OSFM are the reports and violations that apply to the Mitigation & Penalties process.
What if you are waiting on current inspections already requested? Do you need mitigation plans for the sites?
No. If violations were corrected and a fire re-inspection has submitted and entered with the OSFM by BALC prior to Aug 1st you do not need to submit a violation list and mitigation plan.
How do we know what our citations are to submit a list of non-compliant fire safety citations by 9/1/21?
The agency is to review the last fire reports issued by the OSFM and compile the list of violations contained on those reports. *If agencies do not have their reports and need assistance from BALC they need to request this in writing as soon as possible by emailing firstname.lastname@example.org with their request. The deadlines put forth will still apply to those agencies requesting help from BALC.
Is this only applicable to CILA's or to all agency sites, including CDS and CMHC?
The immediate timeline, requirements, and penalty process is applicable only to CILA sites with open violations.
For the 4 year fire marshal renewal inspection, are those automatically scheduled or do we contact BALC to schedule?
The 4 year renewal inspection for sites with no open violations will be entered with the OSFM automatically 6 months prior to the due date. The agency will be informed when this occurs.
How is a Repeat Violation defined?
A repeat violation is a consecutive failure on the violation level. This would be a specific violation that was failed during an initial inspection and fails again during the re-inspection. If a site fails a re-inspection for a violation that was not found and documented during the initial inspection the penalty for repeat violation will not be imposed. If a site clears violation(s) but then subsequently fails for that same violation 4 years later this is not considered a repeat violation.
- When will the transition to the 4 year review cycle begin?
- If a home was cleared in 2020, would we expect the next inspection 2024?
- If all our homes were cleared in 2019, does the 4 yr start from 2019, or from now?
-These 3 questions addressed below-
The application of the 4 year quadrennial cycle will be determined based on if the site is within fire inspection compliance based on the current rules at the effective date of Sept 1st 2021. If a site is in compliance, meaning it has passed inspection within two years, the next fire inspection is due four years from the passed inspection date.
*However, due to fire marshal regional scheduling practices, Agency homes will continue to be seen together whenever possible. When this impacts the implementation of the quadrennial cycle, adjustments will be made to ensure the fire marshal can see your homes together and you will be notified.
EXP A: Home A passed fire inspection on 9/21/19. If there are no open violations, this home is due for fire inspection September 2023.
EXP B: Home B passed fire inspection 7/4/2019, This home is due for fire inspection. If it has no open violations this site is due and should be requested and entered for inspection with the OSFM. If the site passes, the next required inspection is 4 years from the passed due.
EXP C: Home C passed fire inspection 10/15/19, but was already entered for renewal fire inspection around April 2021. This year's inspection will go ahead. If the inspection this year fails, violations will need to be remediated and corrected. The 4 year cycle will be set after the next passing re-inspection.
EXP D: Home D passed fire inspection 12/20/19. All other homes for the agency passed 7/1/21. Home D will be seen in 2021. The 4 year cycle will be set after the next passing re-inspection.
Provider Level EXP: When a provider adds a site 3 years into the 4 year cycle that new home will be seen with the rest of the homes when the provider is up. For example, new home is added 8/1/21 but agency is up for renewal 6/1/22. The site that was just added on 8/1/21 will be reentered with all of the sites so that the agency can get on one cycle.
Is there a checklist that OSFM uses to assure our compliance?
BALC does not have a checklist the highlights what an OSFM fire inspector looks for during an inspection. The inspections are based on the current NFPA 101 Life Safety Code and the interpretation and application of the fire code must come from the Office of the State Fire Marshal. However, there are resources available to the public. The Office of the State Fire Marshal Technical Services Division website is a good reference for this to ensure you are knowledgeable about the requirements you homes need to comply with to operate safely:
OSFM Technical Services Division
Free access NFPA codes and standards
NFPA Life Safety Code Updates
Can you clarify if all sites must be corrected before we can ask for the fire marshal to come back out or if we have one site corrected can we submit to have that home re-inspected?
No, all sites do not need to be corrected before you can submit Mitigation Plans and Fire Re-inspection requests. You may submit plans and inspections requests when a particular site has all violations corrected and is ready to pass a re-inspection.